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Indiana House Bill HB1191

Indiana 2024 Regular Session

Indiana House Bill HB1191 Compare Versions

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22 Introduced Version
33 HOUSE BILL No. 1191
44 _____
55 DIGEST OF INTRODUCED BILL
66 Citations Affected: IC 12-7-2-1.6; IC 12-15.
77 Synopsis: Medicaid matters. Allows a provider that has entered into
88 a contract with a managed care organization, after exhausting any
99 internal procedures of the managed care organization for provider
1010 grievances and appeals, to request an independent review of the
1111 managed care organization's action with an independent third party
1212 provider selected by the office of Medicaid policy and planning.
1313 Establishes a procedure for an independent third party provider to
1414 review an action of a managed care organization. Prohibits a provision
1515 in a contract between a provider and a managed care organization that
1616 would negate or restrict the right of a provider to an independent
1717 review and provides that such a contract provision is void and
1818 unenforceable. Provides that if the office of the secretary of family and
1919 social services (office) or a contractor of the office fails to pay or
2020 denies a clean claim for any eligible Medicaid service within certain
2121 time limits due to the office or contractor incorrectly processing the
2222 clean claim because of errors attributable to the internal system of an
2323 insurer or managed care organization, the office or contractor may not
2424 assert that the provider failed to meet the timely filing requirements for
2525 the claim. Changes the membership of the Medicaid advisory
2626 committee (committee). Allows a member of the committee whose
2727 position was eliminated to continue to serve until the member's term
2828 expires. Establishes co-chairs for the committee and provides that the
2929 elected co-chair of the committee serves for a two year term. Requires
3030 the office to prepare a report that describes every type of report that
3131 must be prepared by a Medicaid contractor or managed care entity and
3232 submitted to the office or the office of Medicaid policy and planning.
3333 (Continued next page)
3434 Effective: July 1, 2024.
3535 Clere
3636 January 9, 2024, read first time and referred to Committee on Public Health.
3737 2024 IN 1191—LS 6959/DI 147 Digest Continued
3838 Specifies the information that must be contained in the report. Requires
3939 the office to submit the report to the committee and the general
4040 assembly. Requires the committee to hold public hearings on the
4141 report. Makes technical changes.
4242 2024 IN 1191—LS 6959/DI 1472024 IN 1191—LS 6959/DI 147 Introduced
4343 Second Regular Session of the 123rd General Assembly (2024)
4444 PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
4545 Constitution) is being amended, the text of the existing provision will appear in this style type,
4646 additions will appear in this style type, and deletions will appear in this style type.
4747 Additions: Whenever a new statutory provision is being enacted (or a new constitutional
4848 provision adopted), the text of the new provision will appear in this style type. Also, the
4949 word NEW will appear in that style type in the introductory clause of each SECTION that adds
5050 a new provision to the Indiana Code or the Indiana Constitution.
5151 Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
5252 between statutes enacted by the 2023 Regular Session of the General Assembly.
5353 HOUSE BILL No. 1191
5454 A BILL FOR AN ACT to amend the Indiana Code concerning
5555 human services.
5656 Be it enacted by the General Assembly of the State of Indiana:
5757 1 SECTION 1. IC 12-7-2-1.6 IS ADDED TO THE INDIANA CODE
5858 2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
5959 3 1, 2024]: Sec. 1.6. "Administrator of the office" refers to the
6060 4 administrator of the office of Medicaid policy and planning
6161 5 appointed under IC 12-8-6.5-2.
6262 6 SECTION 2. IC 12-15-11-11 IS ADDED TO THE INDIANA
6363 7 CODE AS A NEW SECTION TO READ AS FOLLOWS
6464 8 [EFFECTIVE JULY 1, 2024]: Sec. 11. (a) As used in this section,
6565 9 "action" means:
6666 10 (1) a denial of reimbursement for claims submitted for
6767 11 covered services to an applicant, a pending applicant, a
6868 12 conditionally eligible individual, or a member; or
6969 13 (2) a reduction in reimbursement for claims submitted for
7070 14 covered services to an applicant, a pending applicant, a
7171 15 conditionally eligible individual, or a member.
7272 2024 IN 1191—LS 6959/DI 147 2
7373 1 (b) As used in this section, "contracted provider" means a
7474 2 provider that has entered into a contract with a managed care
7575 3 organization or a contractor of the office.
7676 4 (c) As used in this section, "office" refers to the office of
7777 5 Medicaid policy and planning established by IC 12-8-6.5-1.
7878 6 (d) Except as provided in this section, the right of a provider
7979 7 contracting with a managed care organization to dispute an action
8080 8 by the managed care organization is governed by the provider's
8181 9 contract with the managed care organization.
8282 10 (e) A contracted provider that is directly affected by an action
8383 11 of a managed care organization, after exhausting any internal
8484 12 procedures of the managed care organization for provider
8585 13 grievances and appeals, may file a request for an independent
8686 14 review of the managed care organization's action with an
8787 15 independent third party provider selected by the office.
8888 16 (f) The office shall establish the procedures and protocols for an
8989 17 independent review under this section, which must include the
9090 18 following:
9191 19 (1) The review must be initiated by the filing of a request for
9292 20 an independent review by the contracted provider.
9393 21 (2) The independent review shall be conducted by an
9494 22 independent third party provider that:
9595 23 (A) is not related to or affiliated with the contracted
9696 24 provider or the managed care organization;
9797 25 (B) has the medical knowledge necessary to review the
9898 26 medical issues presented in the review; and
9999 27 (C) shall write a final decision concerning the action of the
100100 28 managed care organization.
101101 29 (3) The primary focus of the independent review must be the
102102 30 medical necessity and other medically appropriate issues
103103 31 concerning the action of the managed care organization.
104104 32 (4) The final decision of the independent third party provider
105105 33 is binding on the parties and may not be appealed. However,
106106 34 if the contracted provider or managed care organization
107107 35 proves to the office's satisfaction that the independent third
108108 36 party provider did not materially follow the office's policies
109109 37 and procedures, the office, in its sole discretion, may allow a
110110 38 new review by a different independent third party provider.
111111 39 (g) The office shall establish a fee schedule, based on the level of
112112 40 review that is required, for the independent review under this
113113 41 section. The fee must be paid to the independent third party
114114 42 provider upon completion of the provider's responsibilities under
115115 2024 IN 1191—LS 6959/DI 147 3
116116 1 this section.
117117 2 (h) The procedure, time limits, and other provisions set forth in
118118 3 405 IAC 1.1-1 for appeals concerning applicants and recipients of
119119 4 Medicaid apply to reviews under this section.
120120 5 (i) Notwithstanding subsection (e), a contracted provider may
121121 6 not file for an independent review under this section until after
122122 7 December 31, 2025. This subsection expires January 1, 2026.
123123 8 SECTION 3. IC 12-15-11-12 IS ADDED TO THE INDIANA
124124 9 CODE AS A NEW SECTION TO READ AS FOLLOWS
125125 10 [EFFECTIVE JULY 1, 2024]: Sec. 12. (a) A contract between a
126126 11 provider and a managed care organization shall not negate or
127127 12 restrict the right of a provider to an independent review under
128128 13 section 11 this chapter.
129129 14 (b) A contract provision that violates subsection (a) is void and
130130 15 unenforceable.
131131 16 SECTION 4. IC 12-15-13-1.7 IS AMENDED TO READ AS
132132 17 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 1.7. (a) This section
133133 18 does not apply to claims submitted for payment by nursing facilities.
134134 19 (b) The office shall pay or deny each clean claim as follows:
135135 20 (1) If the claim is filed electronically, within twenty-one (21) days
136136 21 after the date the claim is received by:
137137 22 (A) the office; or
138138 23 (B) a contractor of the office under IC 12-15-30, if
139139 24 IC 12-15-30 applies.
140140 25 (2) If the claim is filed on paper, within thirty (30) days after the
141141 26 date the claim is received by:
142142 27 (A) the office; or
143143 28 (B) a contractor of the office under IC 12-15-30, if
144144 29 IC 12-15-30 applies.
145145 30 (c) If:
146146 31 (1) the office fails to pay or deny a clean claim in the time
147147 32 required under subsection (b); and
148148 33 (2) the office or a contractor of the office under IC 12-15-30
149149 34 subsequently pays the claim;
150150 35 the office shall pay the provider that submitted the claim interest on the
151151 36 Medicaid allowable amount of the claim paid under this section.
152152 37 (d) Interest paid under subsection (c) shall:
153153 38 (1) begin accruing:
154154 39 (A) twenty-two (22) days after the date the claim is filed under
155155 40 subsection (b)(1); or
156156 41 (B) thirty-one (31) days after the date the claim is filed under
157157 42 subsection (b)(2); and
158158 2024 IN 1191—LS 6959/DI 147 4
159159 1 (2) stop accruing on the date the claim is paid.
160160 2 (e) In paying interest under subsection (c), the office shall use the
161161 3 same interest rate as provided in IC 12-15-21-3(7)(A).
162162 4 (f) If the office or a contractor of the office denies or fails to pay
163163 5 a clean claim for any eligible Medicaid service within the time
164164 6 allowed by subsection (b) due to the office or contractor incorrectly
165165 7 processing the clean claim because of errors attributable to the
166166 8 internal system of an insurer or a managed care organization, the
167167 9 office or contractor may not assert that the provider failed to meet
168168 10 the timely filing requirements for the claim.
169169 11 SECTION 5. IC 12-15-33-3, AS AMENDED BY P.L.140-2019,
170170 12 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
171171 13 JULY 1, 2024]: Sec. 3. (a) The committee shall be appointed as
172172 14 follows:
173173 15 (1) One (1) member shall be appointed by the administrator of the
174174 16 office to represent each of the following organizations:
175175 17 (A) Indiana Council of Community Mental Health Centers.
176176 18 (B) Indiana State Medical Association.
177177 19 (C) Indiana State Chapter of the American Academy of
178178 20 Pediatrics.
179179 21 (D) Indiana Hospital Association.
180180 22 (E) Indiana Dental Association.
181181 23 (F) Indiana State Psychiatric Association.
182182 24 (G) Indiana State Osteopathic Association.
183183 25 (H) Indiana State Nurses Association.
184184 26 (I) Indiana State Licensed Practical Nurses Association.
185185 27 (J) Indiana State Podiatry Association.
186186 28 (K) Indiana Health Care Association.
187187 29 (L) Indiana Optometric Association.
188188 30 (M) Indiana Pharmaceutical Association.
189189 31 (N) Indiana Psychological Association.
190190 32 (O) Indiana State Chiropractic Association.
191191 33 (P) Indiana Ambulance Emergency Medical Services
192192 34 Association.
193193 35 (Q) Indiana Association for Home and Hospice Care.
194194 36 (R) Indiana Academy of Ophthalmology.
195195 37 (S) Indiana Speech and Hearing Speech-Language-Hearing
196196 38 Association.
197197 39 (T) Indiana Academy of Physician Assistants.
198198 40 (U) Indiana Association of Rehabilitation Facilities.
199199 41 (V) Indiana Association of Health Plans.
200200 42 (W) Indiana Primary Health Care Association.
201201 2024 IN 1191—LS 6959/DI 147 5
202202 1 (2) Ten (10) members shall be appointed by the governor as
203203 2 follows:
204204 3 (A) One (1) member who represents agricultural interests.
205205 4 (B) (A) One (1) member who represents business and
206206 5 industrial interests.
207207 6 (C) (B) One (1) member who represents labor interests.
208208 7 (D) (C) One (1) member who represents insurance interests.
209209 8 (E) One (1) member who represents a statewide taxpayer
210210 9 association.
211211 10 (F) Two (2) members who are parent advocates.
212212 11 (G) Three (3) members who represent Indiana citizens.
213213 12 (D) A representative nominated by AARP Indiana.
214214 13 (E) A representative nominated by The Arc of Indiana.
215215 14 (F) A representative nominated by the Indiana Minority
216216 15 Health Coalition.
217217 16 (G) A representative nominated by the Indiana Rural
218218 17 Health Association.
219219 18 (H) A representative nominated by Mental Health America
220220 19 of Indiana.
221221 20 (I) A representative nominated by an Alzheimer's
222222 21 Association chapter that provides services in at least one
223223 22 (1) county in Indiana.
224224 23 (J) A representative nominated by a United Way that
225225 24 provides services in at least one (1) county in Indiana.
226226 25 (3) Six (6) members shall be appointed by the president pro
227227 26 tempore of the senate acting in the capacity as president pro
228228 27 tempore of the senate to represent the senate. Three (3) of the
229229 28 members appointed under this subdivision shall serve on the
230230 29 standing fiscal subcommittee created under section 8(b) of this
231231 30 chapter.
232232 31 (4) Six (6) members shall be appointed by the speaker of the
233233 32 house of representatives to represent the house of representatives.
234234 33 Three (3) of the members appointed under this subdivision shall
235235 34 serve on the standing fiscal subcommittee created under section
236236 35 8(b) of this chapter.
237237 36 (5) The governor shall rotate the appointment of:
238238 37 (A) a member of a chapter described in subdivision (2)(I)
239239 38 among the chapters described in subdivision (2)(I); and
240240 39 (B) a member of a United Way described in subdivision
241241 40 (2)(J) among the United Ways described in subdivision
242242 41 (2)(J).
243243 42 (b) Notwithstanding subsection (a)(3), after consultation with the
244244 2024 IN 1191—LS 6959/DI 147 6
245245 1 minority leader of the senate, the president pro tempore of the senate
246246 2 shall appoint three (3) of the members from the minority party of the
247247 3 senate.
248248 4 (c) Notwithstanding subsection (a)(4), after consultation with the
249249 5 minority leader of the house of representatives, the speaker of the
250250 6 house shall appoint three (3) of the members from the minority party
251251 7 of the house.
252252 8 SECTION 6. IC 12-15-33-5 IS AMENDED TO READ AS
253253 9 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 5. (a) An appointment
254254 10 to the committee is for a four (4) year term, except the representatives
255255 11 of the senate and house of representatives, whose terms coincide with
256256 12 the representative's or senator's respective legislative terms.
257257 13 (b) Notwithstanding any other law, an individual:
258258 14 (1) who was a member of the committee and was appointed
259259 15 under section 3 of this chapter before July 1, 2024;
260260 16 (2) who on June 30, 2024, had at least one (1) year remaining
261261 17 on the member's term; and
262262 18 (3) whose position to be appointed on the committee was
263263 19 eliminated on July 1, 2024;
264264 20 may continue to serve as a member of the committee until the
265265 21 member's original term expires. This subsection expires July 1,
266266 22 2027.
267267 23 SECTION 7. IC 12-15-33-7 IS AMENDED TO READ AS
268268 24 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 7. (a) The administrator
269269 25 of the office and a member of the committee who is elected at the
270270 26 last meeting of the committee during an odd-numbered year shall
271271 27 serve as secretary co-chairs of the committee.
272272 28 (b) The member of the committee who is elected co-chair under
273273 29 this section shall serve as co-chair for a term of two (2) years.
274274 30 SECTION 8. IC 12-15-33-9 IS AMENDED TO READ AS
275275 31 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 9. The committee shall
276276 32 do the following:
277277 33 (1) Meet at least four (4) times each year, one (1) time in each
278278 34 calendar quarter.
279279 35 (2) Hold special meetings that the committee or the secretary a
280280 36 co-chair requests.
281281 37 SECTION 9. IC 12-15-33-11 IS ADDED TO THE INDIANA
282282 38 CODE AS A NEW SECTION TO READ AS FOLLOWS
283283 39 [EFFECTIVE JULY 1, 2024]: Sec. 11. (a) The office of the secretary
284284 40 shall prepare a report that describes every type of report that must
285285 41 be prepared by a Medicaid contractor or managed care entity and
286286 42 submitted to the office of the secretary or the office. The report
287287 2024 IN 1191—LS 6959/DI 147 7
288288 1 must contain the following information:
289289 2 (1) The name or type of each report that contains only
290290 3 information that is required by federal law or a federal
291291 4 agency.
292292 5 (2) The name or type of each report that contains information
293293 6 that is required by state law or a state agency.
294294 7 (b) For the reports that are identified under subsection (a)(2),
295295 8 the report must contain the following information for each type of
296296 9 report:
297297 10 (1) The purpose of the report.
298298 11 (2) Entities that use the reported information.
299299 12 (3) The manner in which the information is being used.
300300 13 (4) Whether there is information that is required in the report
301301 14 that is not being actively used.
302302 15 (5) Whether there is information in the report that is
303303 16 duplicated in another report.
304304 17 (6) Any data from the report or aggregate data that is
305305 18 available to the public.
306306 19 (c) The report required under this section must contain the
307307 20 following information:
308308 21 (1) Any process that is used to evaluate the purpose and use of
309309 22 the reports, including consolidating or eliminating reports.
310310 23 (2) Recommendations on how to make information from the
311311 24 reports and data held by the office of the secretary that is
312312 25 compliant with the federal Health Insurance Portability and
313313 26 Accountability Act (HIPAA) available to the general
314314 27 assembly, Medicaid contractors, managed care entities, and
315315 28 the public to be used for accountability, policymaking, and
316316 29 innovation purposes.
317317 30 (d) The report required under this section must be submitted
318318 31 before October 1, 2024, to the:
319319 32 (1) committee; and
320320 33 (2) general assembly in an electronic format under IC 5-14-6.
321321 34 (e) The committee:
322322 35 (1) shall hold public hearings on the report; and
323323 36 (2) may make recommendations to the office of the secretary
324324 37 and the general assembly.
325325 38 (f) This section expires July 1, 2025.
326326 2024 IN 1191—LS 6959/DI 147